Combination of electromagnetic navigation bronchoscopy-guided biopsy with a novel staining for peripheral pulmonary lesions

Abstract

Background: The diagnosis of peripheral pulmonary lesions (PPLs) is a challenging task for pulmonologists, especially for small PPLs. Conventional localization of these small PPLs, which are > 1 cm away from the visceral pleura in operation, is quite difficult. Currently used methods inevitably damage the visceral pleura and may cause a series of complications, such as pneumothorax and hemothorax. Hence, the present study aimed to find out an intraoperative localization method with no damage to the visceral pleura.

Methods: We retrospectively reviewed 21 patients with PLLs who underwent electromagnetic navigation bronchoscopy (ENB)-guided biopsy plus a new methylene blue staining with the help of massage (Massage Staining) in our department between August 2017 and December 2018.

Results: The median age of these 21 patients was 51.3 ± 2.1 years. The diameter of the PPLs was 8.2 ± 2.3 mm. The rate of successful biopsy was 76.2%, and the rate of excellent or satisfactory of Massage Staining was 81.0%, while all lesions of these 21 cases were included in the range of staining, and the median distance from the edge of the stained site to the edge of the lesion was 29 ± 18 mm. The duration of ENB-guided biopsy plus Massage Staining was 26.7 ± 5.3 min, and the intraoperative blood loss was 3.3 ± 1.5 ml. No pneumothorax, hemorrhage, and tracheal injury occurred intraoperatively.

Conclusions: The ENB-guided biopsy combined with Massage Staining is an innovative one-stop strategy designed to enhance the precision of thoracic surgery. The Massage Staining avoids damage to the visceral pleura, causes the low incidence of complications, but yields precise localization of PPLs.

Keywords: Biopsy; Electromagnetic navigation bronchoscopy; Peripheral pulmonary lesions; Staining.

Fig. 1

Preoperative preparation. a Preoperative CT scan was carried out to determine the location of the lesion; the red arrow shows the lesion. b Preoperatively establish the navigation path by ENB, in which the green point is a lesion

Fig. 2

Surgical procedure for ENB-guided biopsy combined with massage staining. a The locatable guide wire and the extended working channel reached the lesion. b The locatable guide wire and the extended working channel reached the visceral pleura. c The methylene blue was injected through cannula with the dose of 0.8 ml/cm of the lesion diameter. d The catheter with methylene blue was placed into the extended working channel, and the direction of catheter rubbing during the staining was shown by the red arrow

Fig. 3

a–c Schematic diagram of a novel Massage Staining

Fig. 4

The proposed strategy for surgical treatment by a combination of ENB-guided biopsy with Massage Staining. The red arrow represents the lesion is malignant according to the results of frozen section diagnosis

Fig. 5

Criteria for evaluation of the dyeing effect. Excellent: the distance from the edge of the lesion to the edge of staining was less than 20 mm. Satisfactory: the distance from the edge of the lesion to the edge of staining was 20–40 mm. Unsatisfactory: the distance from the edge of the lesion to the edge of staining was more than 40 mm

Fig. 6

Intraoperative observation of the proposed Massage Staining. a The effects of staining where the catheter reached the visceral pleura. b The effects of staining where the distance from the catheter to the visceral pleura was about 0.8 cm